Introduction: Delivery of higher value healthcare is an ultimate government and public goal. Improving efficiency in the operating room and standardization of surgical steps would improve patient outcome and reduce costs, and lead to higher value healthcare. Lean principles have been applied to processes proceeding and following surgery and have improved timeliness; however, value stream mapping of surgery itself has not been performed, therefore pure waste has not been targeted for improvement. We applied plan, do, study, act (PDSA) cycles to posterior instrumented fusion (PIF) in an attempt create a standard work flow, identify waste and remove special cause variability among similar cases.

Methods: An evaluation PSDA cycle was performed as quality improvement by creation of value stream maps for 5 PIF procedures from a single faculty neurosurgeon. Plan = segment PIF, into basic components, Do = mapping and timing components, Study = analyzing results, and Act = identifying waste for elimination. Waste inventory, spaghetti diagram, and charting of time spent per step were performed. Common steps including exposure, decompression/discectomy, hardware placement and closure were analyzed with box and whisker plots to evaluate extent of variability.

Results: Procedural steps were defined, resulting in interchangeable modules, which could be studied despite the variability in PIF. Step duration for decompression vs. closure and hardware vs. closure were significantly different (p=0.003). Variability in procedural step duration was smallest for closure and largest for exposure. Wastes including waiting and defects accounted for 15% and 66%, respectively.

Conclusions: Lean principles can be applied to neurosurgical procedure time, and can be used to standardize surgical work-flow and identify waste; common to all procedures was waiting and defect waste from non-surgical sources. This preliminary data was the basis of a quality improvement Kaizen event to decrease causes of variability, improve efficiency and decrease overall cost.

Patient Care: Process improvement is an ongoing universal endeavor to improve the value of health care; improved value means better population-level outcomes and better experience of care for an individual all at lower cost. Decreasing operating room times makes procedures less expensive and minimizes patient risk under anesthesia.

Learning Objectives: By the conclusion of this session participants should be aware that application of lean principles can 1. standardize surgical work flow 2. identify waste 3. lead to the elimination of special cause variability, which delays operative room time.

References: 1. Porter ME, Lee T: The strategy that will fix healthcare. HBR 2013, http://hbr.org/2013/10/the-strategy-that-will-fix-health-care/ar/pr 2. Mahoney C: Reducing OR inefficiencies improves financial results. AAOS Now 9:1, January 2015.